Steps to Implement a
POLST Paradigm Program
Patricia A. Bomba, M.D., F.A.C.P.
Vice President & Medical Director, Geriatrics
Excellus BlueCross BlueShield
Chair, Monroe & Onondaga Counties MOLST Implementation Team
Co-Director, Community-Wide End-of-life/Palliative Care Initiative
Patricia.Bomba@lifethc.com
Objective
 Identify steps to implement a POLST
Paradigm system in a state or region
 Demonstrate how these steps work
Implementation Steps
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Needs Assessment
Core Working Group
Task Force – Collaborative Model
Program Coordination
Key Components
Legal Issues
Pilot Project
Education and Training
Distribution and Fulfillment
Program Requirements
Relationship to Media
Available Resources
Needs Assessment
 System responsiveness
 Honoring patient preferences for EOL care
 DNR, Life-sustaining Treatment, Site of Death
 Interdisciplinary Approach
 Facilities: hospitals, SNFs, ALFs, DM programs
 Disciplines: MD, RN, SW, EMS, Atty, consumers
 Data-driven
 Build on current research
Core Working Group
 Assemble a workgroup
 Broad representation – interdisciplinary
 Leadership
 Passion, commitment
 Willing to outreach and educate
 Sustainability
 Expand collaboration
Task Force – Collaborative Model
 Broad representation: state, regional & local
 Department of Health
 Hospital, LTC, EMS oversight, surveyors
 EMS
 Hospital Association
 Long-term Care Associations (NFP and FP)
 Hospice and Home Health
 Office for Aging, Society on Aging, Ombudsmen
 Medical Society
 Bar Association
Program Coordination
 Leadership
 Operations
 Distribution and Fulfillment
 Training
 Quality Improvement
 Share best practices & lessons learned
 Funding
 Sustainability
 Variation in models
Key Components
 Standardized practices, policies and form
 Education and Training
 Advance care planning facilitators
 System implementation
 Timely discussions along continuum prompted by:
 Identification of appropriate cohort
 Prognosis
 Clear, specific language on actionable form
 Bright colored, easily recognized form
 Medical orders honored throughout the system
 Quality improvement process for form and system
Core Working Group
 Educate and empower
 Research - Evidence base
 View www.polst.org
 NQF Preferred Practices
 Web resources
 State-specific information
 State contacts
 Links to other state web sites
Web Site Resources
www.polst.org
www.wvendoflife.org
www.wsma.org/patients/polst
Center for Ethics in Health Care Oregon
Health & Science University
West Virginia Center for End-of-Life Care:
POST
Washington State Medical Association:
POLST
www.compassionandsupport.org New York State Community-Wide End-of-life/
Palliative Care Initiative: MOLST
www.eperc.mcw.edu
www.hardchoices.com
End of life and palliative care education
resource center
“Hard Choices for Loving People”:
A resource for professionals, patients and their families
regarding end-of-life treatment decisions
Advance Care Planning Community Goals
 Document the designated surrogate/decision
maker in accordance with state for every patient
in primary, acute and long-term care and in
palliative and hospice care.
 Document the patient/surrogate preferences for
goals of care, treatment options, and setting of
care at first assessment and at frequent intervals
as condition changes.
National Quality Forum, Framework and Preferred Practices
for Quality Palliative Care & Hospice Care, 2006
Advance Care Planning Community Goals
 Convert the patient treatment goals into medical
orders and ensure that the information is
transferable and applicable across care settings,
including long-term care, emergency medical
services, and hospital care through a program
such as the POLST Program.
National Quality Forum, Framework and Preferred Practices
for Quality Palliative Care & Hospice Care, 2006
Advance Care Planning Community Goals
 Make advance directives and surrogacy
designations available across care settings
 Develop and promote healthcare and community
collaborations to promote advance care planning
and completion of advance directives for all
individuals (e.g. the Respecting Choices and
Community Conversations on Compassionate
Care programs.)
National Quality Forum, Framework and Preferred Practices
for Quality Palliative Care & Hospice Care, 2006
Legal Issues
 State regulations or need for legislation
 Legislative approach (WV, TN, HI)
 Regulatory approach (OR, UT, WA)
 Hybrid approach (NY)
 Patient’s/legal agent’s signature
 Mandatory or optional
 Practitioner’s Signature other than MD
 Need for legislation, potential opposition
 Acceptable policies & procedures with current
regulations
Pilot Project
 Voluntary
 Community consensus of key players
 Training
 Distribution & fulfillment of materials
 Establish key outcomes
 Measure regularly
 Share results with key stakeholders
Education and Training
 Advance Care Planning Facilitators
 Traditional advance directives
 POLST Paradigm form
 Goal-based, patient-centered discussions
 Patient-centered program and process
 not merely the form
 Program Implementation
 Facility-based
 Physician practice – opportunity for process
improvement
 Community education
Distribution and Fulfillment
 Distribution Center
 Process to order forms, educational and
training resources
 Download from web site
 Considerations
 Funding
 Tracking utilization and implementation
Program Requirements
 Review requirements on-line, view
http://www.ohsu.edu/polst/corereqs.shtml
 Apply on-line for endorsement, view
http://www.ohsu.edu/polst/coreform.shtml
Relationship to Media
 Communication Plan
 Messaging
 Consistent message
 Approach to avoid
 Prepare for interviews
 Consider 3 key messages
Web Site Resources
www.polst.org
www.wvendoflife.org
www.wsma.org/patients/polst
Center for Ethics in Health Care Oregon
Health & Science University
West Virginia Center for End-of-Life Care:
POST
Washington State Medical Association:
POLST
www.compassionandsupport.org New York State Community-Wide End-of-life/
Palliative Care Initiative: MOLST
www.eperc.mcw.edu
www.hardchoices.com
End of life and palliative care education
resource center
“Hard Choices for Loving People”:
A resource for professionals, patients and their families
regarding end-of-life treatment decisions
Thank You
For further information , view
www.compassionandsupport.org
Patricia A. Bomba, M.D., F.A.C.P.
Vice President & Medical Director, Geriatrics
Excellus BlueCross BlueShield
Patricia.Bomba@lifethc.com